How to Handle an Appeal in 3 Steps

Let’s face it, insurance claims get denied. When it happens, it’s important to understand what recourse you have. In most cases, you have the right to appeal the claim and still receive reimbursement for the service. Here’s how:

1.) Understand WHY the Claim Was Denied

• The first step is to review the EOB and determine the exact reason for the denial. All too often the EOB language used is not straightforward. As an example: “procedure is inclusive of another” generally means “not enough documentation was provided.”

• If you don’t fully understand the reasoning behind the denial, it can help to call the carrier for more information.

• For the best chance of succeeding, you must understand the WHY before you can respond with an appeal.

2.) Request for Reconsideration

Do not submit a new claim. Send a written letter for an appeal or reconsideration to the carrier, which should be on your practice letterhead. The letter should clearly state that it is a “Request for Appeal” and should include:

• The Claim Number of the original case. 

• Write a brief and clear reason for the appeal.

• Describe the clinical scenario, why it matches the coding, and why the treatment provided to the patient should be covered.

• Attach any supporting documentation, including the documentation that was sent with the original claim (often the appeal will be assigned to another reviewer, who may not have access to the original claim). Radiographs, photos, charting, narratives, and relevant clinical notes can add helpful insight to a case.

• Clearly mark on the original claim that this is an “Appeal” or “Review Request.”

• State the best way to respond back to you: who, when (days/week and times), how (phone number).

  
  

Be sure to send it to the correct address! The appeals department and address can often be different from the original claims department address. Check the EOB to make sure you are sending it to the right location.

3.) Follow Up

If you do not receive a response within 30 days, you should follow up with the Appeal’s Department to ensure they did, in fact, receive the appeal as well as let them know that you have not received a response.

If the claim is denied a second time, you have one more try. At this point, it might be highly useful to have the patient get involved. Most carriers allow you to request a dentist-to-dentist discussion between the treatment provider and the dental consultant. These meetings can be quite helpful if you are well-prepared and handle the conversation professionally.

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About the Author

Dr. Travis Campbell has been a practicing dentist since 2009, after graduating from Baylor University in Waco, Texas and then Baylor College of Dentistry in Dallas, Texas. He is an author, trainer, speaker at dental conferences, a contributor to various online dental communities, and dental coach/consultant. Ever an entrepreneur, Dr. Campbell purchased a second dental practice, in Garland, Texas in the fall of 2019.

Having gained a reputation as an expert in the complex area of dental insurance, Dr. Campbell’s new “moniker” is “The Dental Insurance Guy.” From understanding insurance to developing strategies to accelerate practice growth, Dr. Campbell delivers practical, actionable content that dentists and team members can use immediately. He dispels many of the myths and misinformation around today’s dental insurance policies and explains how to navigate the complexities of being an exceptional dentist, business owner, and leader.

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The Dental Insurance Guy simplifies dental insurance by helping dentists and their teams navigate claims, maximize reimbursements, and improve patient communication.

With expert insights, practical strategies, and step-by-step guidance, he empowers practices to optimize insurance processes, reduce headaches, and increase profitability. Whether you're dealing with denied claims, fee negotiations, or patient benefits, the Dental Insurance Guy provides the knowledge and tools to streamline your workflow and get paid what you deserve.